COVID-19 Self-Collected Antibody Test System EUA Summary: June 24, 2021 EMERGENCY USE AUTHORIZATION (EUA) SUMMARY COVID-19 SELF- COLLECTED ANTIBODY TEST SYSTEM (Symbiotica, Inc.) For In vitro Diagnostic Use Rx Only For use under Emergency Use Authorization (EUA) only For use with samples that are self-collected by an individual age 18 years or older, or that are collected by an adult from an individual 5 years of age and older. (Testing of specimens collected using the COVID-19 Self-Collected Antibody Test System will be performed at Symbiotica, Inc., Vacaville, CA, a laboratory certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a that meets the requirements to perform high complexity tests as per the Standard Operating Procedure (SOP) that was reviewed by the FDA under this EUA.) INTENDED USE The COVID-19 Self-Collected Antibody Test System is an enzyme-linked immunosorbent assay (ELISA) and a blood collection kit intended for qualitative detection of IgG antibodies to SARS- CoV-2 in human fingerstick blood dried blood spot (DBS) samples that are self-collected at home by an individual age 18 years or older or that are collected by an adult from an individual 5 years of age or older using the COVID-19 Self-Collected Antibody Test System Collection Kit when determined to be appropriate by a healthcare provider. The COVID-19 Self-Collected Antibody Test System is intended for use as an aid in identifying individuals with an adaptive immune response to SARS-CoV-2, indicating recent or prior infection. The COVID-19 Self-Collected Antibody Test System should not be used to diagnose or exclude acute SARS-CoV-2 infection. At this time, it is unknown for how long antibodies persist following infection and if the presence of antibodies confers protective immunity. The COVID-19 Self-Collected Antibody Test System includes the COVID-19 Self-Collected Antibody Test System Collection Kit for use to self-collect fingerstick dried-blood spot specimens at home by individuals described above when determined to be appropriate by a healthcare provider. Testing is limited to Symbiotica, Inc., located at 1350 Burton Drive, Ste 210 Vacaville, CA 95687, which is certified under Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. §263a, and meets requirements to perform high-complexity tests. Results are for the detection of SARS-CoV-2 antibodies. IgG antibodies to SARS-CoV-2 are generally detectable in blood several days after initial infection, although the duration of time antibodies are present post-infection is not well characterized. Individuals may have detectable virus present for several weeks following seroconversion. Laboratories within the United States and its territories are required to report all results to the appropriate public health authorities. 1 COVID-19 Self-Collected Antibody Test System EUA Summary: June 24, 2021 The sensitivity of COVID-19 Self-Collected Antibody Test System early after infection is unknown. Negative results do not preclude acute SARS-CoV-2 infection. If acute infection is suspected, direct testing for SARS-CoV-2 is necessary. False positive results for COVID-19 Self-Collected Antibody Test System may occur due to cross- reactivity from pre-existing antibodies or other possible causes. The COVID-19 Self-Collected Antibody Test System is only for use under the Food and Drug Administration’s Emergency Use Authorization. DEVICE DESCRIPTION AND TEST PRINCIPLE The COVID-19 Self-Collected Antibody Test System comprises a collection kit, the COVID-19 Self-Collected Antibody Test System Collection Kit, which is delivered to individuals for home collection, and an ELISA assay, which is performed using the self-collected samples. The assay, part of the COVID-19 Self-Collected Antibody Test System, is referred to as the COVID-19 eSTAD. The COVID-19 eSTAD is based on the EUROIMMUN Anti-SARS-CoV-2 Assay (EUA200523) and provides qualitative in vitro determination of human antibodies of the immunoglobulin class IgG against SARS-CoV-2. The collection kit, part of the COVID-19 Self- Collected Antibody Test System, includes the necessary components for individuals to self-collect a sample for testing using the assay. The COVID-19 Self-Collected Antibody Test System Collection Kit consists of an instruction sheet, one PerkinElmer DBS card (product number GRNK 11022; product code ZV 9956-01100), two safety lancets, two sterile gauze pads, two alcohol prep pads, two Band Aids, and a return mailer with a prepaid label. Medical oversight of the process is provided by independent third-party healthcare professionals. Individuals may request the COVID-19 Self-Collected Antibody Test System on an online platform or through their physician visit. Physicians who are interested in ordering the COVID-19 Self-Collected Antibody Test System for their patients will be provided with Symbiotica’s test requisition form, which can be returned to Symbiotica via Symbiotica’s HIPAA-compliant fax system. An HCP, licensed in the state where the participant is located, will determine eligibility based on a COVID-19 health history questionnaire, and will order testing when appropriate. Collection kits, part of the COVID-19 Self-Collected Antibody Test System, will only be sent to participants meeting the inclusion criteria based on the information provided by the HCP from the COVID-19 health history questionnaire and prescribed by HCPs. Kits will be shipped directly to the patients’ home, who will collect their sample at home. Patients will return their sample using the provided mailer and return label. When results are ready, Symbiotica will make the reports ready using an agreed upon method, which includes, but not limited to, an online platform, HIPAA-compliant fax, or mailed to the physician’s office. The HCP will attempt to contact the patient as soon as possible to deliver results and provide education via a telemedicine visit or phone consultation. Test results are made available upon completion of HCP contact protocols. 2 COVID-19 Self-Collected Antibody Test System EUA Summary: June 24, 2021 COMPONENTS SPECIFIC TO THE KIT The COVID-19 Self-Collected Antibody Test System is comprised of the following: 1. COVID-19 Self-Collected Antibody Test System Collection Kit: The collection kit consists of an instruction sheet, one PerkinElmer DBS card (product number GRNK 11022; product code ZV 9956-01100), two safety lancets, two sterile gauze pads, two alcohol prep pads, two Band Aids, and a return mailer with a prepaid label. 2. COVID-19 eSTAD assay: The test kit contains microplate strips each with 8 break-off reagent wells coated with recombinant structural protein of SARS-CoV-2. In the first reaction step, diluted patient samples are incubated in the wells. In the case of positive samples, specific IgG antibodies will bind to the antigens. To detect the bound antibodies, a second incubation is carried out using an enzyme-labelled anti-human IgG (enzyme conjugate) catalyzing a color reaction. Table 1. Components of the COVID-19 eSTAD assay kit 1 Microplate wells coated with antigens 12 microplate strips each containing 8 individual break-off wells in a frame, ready for use 2 Calibrator (IgG, human), ready for use 3 Positive control (IgG, human), ready for use 4 Negative control (IgG, human), ready for use 5 Enzyme conjugate peroxidase-labelled anti-human IgG, ready for use 6 Sample buffer ready for use 7 Wash buffer 10x concentrate 8 Chromogen/substrate solution TMB/H2O2, ready for use 9 Stop solution 0.5 M sulphuric acid, ready for use CONTROLS TO BE USED WITH THE COVID-19 DRIED BLOOD SPOT COLLECTION KIT The controls and calibrator included in the test kit must be used with each run. Results cannot be validated if the control values deviate from the expected values stated on the quality control certificate. If the values specified for the controls are not achieved, the test results may be inaccurate and the test should be repeated. The positive control and negative control are intended to monitor for substantial reagent failure, but will not ensure precision at the assay cut-off. INTERPRETATION OF RESULTS Assessment of the COVID-19 Self-Collected Antibody Test System results should be performed after the positive and negative controls have been examined and determined to be valid and acceptable. If the controls are not valid, the patient results cannot be interpreted. 3 COVID-19 Self-Collected Antibody Test System EUA Summary: June 24, 2021 Results are evaluated qualitatively by calculating a ratio of the extinction of the control or patient sample over the extinction of the calibrator. The ratio is calculated according to the following formula: ÷ = ℎ The cut-off for negative samples is ratio <0.8. The positive threshold is ratio ≥1.1. The indeterminate range is ratio ≥0.8 to <1.1. PERFORMANCE EVALUATION 1) Analytical Specificity Cross reactivity Potential cross-reactivity with antibodies to commonly identified pathogens in the general community was evaluated with the Euroimmun Anti-SARS-CoV-2 ELISA (IgG), which was EUA authorized on 04 May 2020 (EUA200523). The details of the performance of the authorized Euroimmun Anti-SARS-CoV-2 ELISA (IgG) can be found in the Euroimmun Anti-SARS-CoV-2 ELISA (IgG) Instructions for Use. Euroimmun granted Right of Reference to Symbiotica for this data. Class Specificity Class specificity was evaluated with the EUROIMMUN Anti-SARS-CoV-2 ELISA (IgG), which was EUA authorized on 04 May 2020. The details of the performance of the authorized Euroimmun Anti-SARS-CoV-2 ELISA (IgG) can be found in the Euroimmun Anti-SARS-CoV-2 ELISA (IgG) Instructions for Use. Euroimmun granted Right of Reference to Symbiotica for this data. 2) Clinical Performance Clinical Sensitivity The positive percent agreement (PPA) of the COVID-19 Self-Collected Antibody Test System was evaluated in 32 unique DBS samples from symptomatic patients who were confirmed as SARS- CoV-2 positive via RT-PCR at least 8 days but no more than 45 days prior to sampling.